The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review

Dermatol Ther (Heidelb) DOI 10.1007/s13555-017-0207-0 REVIEW The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review Isabelle M. Sanchez . Eric Sorenson . Ethan Levin . Wilson Liao Received: September 22, 2017 Ó The Author(s) 2017. This article is an open access publication ABSTRACT Introduction: Palmoplantar psoriasis (PP) and palmoplantar pustulosis (PPP) are diseases affecting the hands and/or feet that can cause marked physical discomfort and functional disability. The tumor necrosis factor-alpha antagonists adalimumab, etanercept, and infliximab, the interleukin (IL)-17A inhibitors ixekizumab and secukinumab, and the IL-23 or IL-12/IL-23 inhibitors guselkumab and ustekinumab have been well studied for the treatment of moderate to severe plaque psoriasis. Enhanced content To view enhanced content for this article go to http://www.medengine.com/Redeem/ 1CCCF0605FC14A88. Isabelle M. Sanchez and Eric Sorenson contributed equally. Electronic supplementary material The online version of this article (doi:10.1007/s13555-017-0207-0) contains supplementary material, which is available to authorized users. I. M. Sanchez (&)
E. Levin
W. Liao Department of Dermatology, University of California San Francisco, San Francisco, USA e-mail: I. M. Sanchez University of Illinois at Chicago College of Medicine, Chicago, USA E. Sorenson Division of Dermatology, University of California Los Angeles, Los Angeles, USA Less is known about the efficacy and safety of these agents for the treatment of PP (hyperkeratotic and pustular forms) and PPP. The aim of this review was to investigate the efficacy of biologic therapy for the treatment of hyperkeratotic PP, pustular PP, and PPP. Methods: A systematic search of the medical electronic databases (Medline, Embase, and Cochrane Library) was conducted to identify studies or case reports which both used biologic therapy for the treatment of hyperkeratotic PP, pustular PP, and PPP and reported treatment outcomes. Results: The systematic search identified 579 published articles, of which 44 were included in the analysis. Seven of the articles involved randomized placebo-controlled trials, two were open label trials, and the remaining were cohort studies, case series, or case reports. In the randomized controlled trials on the treatment of hyperkeratotic PP, adalimumab, guselkumab, infliximab, ixekizumab, and secukinumab each demonstrated superiority to placebo at 16, 16, 14, 12, and 12 or 16 weeks, respectively (p\0.05). For the treatment of pustular PP, ustekinumab 45 mg was not superior to placebo at 12 and 16 weeks, respectively (p[0.05), although an open label study demonstrated that four of five patients on a therapeutic regimen of ustekinumab 90 mg achieved clinical clearance at 16 weeks. For the treatment of PPP, etanercept and ustekinumab 45 mg were not superior to placebo at 12 and 16 weeks, respectively Dermatol Ther (Heidelb) (p[0.05). A combined analysis of studies for hyperkeratotic PP demonstrated that 94.7%, 90.0%, 82.5%, 89.1%, and 86.7% of patients experienced an improvement of at least 50% upon treatment with adalimumab, guselkumab, ixekizumab, secukinumab, and ustekinumab, respectively. In a combined analysis of case reports examining PPP, infliximab showed the greatest efficacy at 100.0% clinical improvement of patients from case reports, followed by ustekinumab at 58.8% clinical improvement. Few serious adverse events were reported, but several were reported in patients treated with infliximab or secukinumab. Conclusion: Biologic therapy is effective and well-tolerated for the treatment of hyperkeratotic PP, but less data are available on the treatment of pustular PP or PPP. Adalimumab, guselkumab, ixekizumab, secukinumab, and ustekinumab all showed[80% efficacy for the treatment of hyperkeratotic PP, while infliximab and ustekinumab showed moderate efficacy for the treatment of pustular PP, and infliximab was the most efficacious treatment for PPP. Keywords: Adalimumab; Biologic therapy; Etanercept; Infliximab; Ixekizumab; Palmoplantar psoriasis; Palmoplantar pustulosis; Pustular psoriasis; Secukinumab; Ustekinumab INTRODUCTION Palmoplantar psoriasis (PP) is a chronic, debilitating disease of the palms and/or soles that affects 11–39% of psoriasis patients [1–3]. The morphology of PP can range from thick, hyperkeratotic plaques with fissuring to pustular lesions of the palms and/or soles, and PP is often classified into subtypes based on this morphologic distinction [4, 5]. Hyperkeratotic PP refers to sharply defined erythematous scaly plaques with overlying hyperkeratosis and without the presence of sterile pustules, predominantly at the palms and/or soles [6]. Pustular PP is a variant that includes macroscopic sterile pustules and erythema with intermixed yellow–brown macules localized to the palms and/or soles [6]. PP causes greater physical discomfort and functional disability than psoriasis limited to other body areas, and it is often recalcitrant to treatment [2]. Palmoplantar pustulosis (PPP) is a bilateral, symmetric dermatosis that also affects the hands and/or feet and is clinically distinguished from PP based on the absence of psoriasis at other body sites and a predilection for histologic involvement of the acrosyringium (the terminal duct of eccrine sweat glands) [6, 7]. Pustular PP and hyperkeratotic PP mostly occur concomitantly with psoriasis at other body areas, while PPP consists of pustular lesions typically limited to the palms and/or soles that appear on a clear, non-erythematous background [6–8]. However, whether PPP can be considered a clinical spectrum of plaque psoriasis or whether it is an independent disease is open to much debate. Consequently, in the literature, pustular PP and PPP are often not well distinguished. Some studies have identified the involvement of the acrosyringium as being more specific to PPP [7, 9]. Demographically, PPP is characterized by a female predominance and strong association with smoking, whereas no such associations exist for pustular PP [6, 7]. Interestingly, in individuals with PPP, nicotine is thought to be secreted into eccrine glands to promote inflammation and alter the local response to infection [7]. Recent genetic studies have challenged the relationship of PPP with plaque psoriasis, although both these conditions can respond to similar treatments and have a similar impact on quality of life. Topical therapy and phototherapy are first-line modalities for the management of PP and PPP. However, the majority of patients eventually require treatment with systemic medications [3]. Traditionally, agents such as oral retinoids, methotrexate, and cyclosporin have been utilized, but these medications carry risks of adverse effects that may limit their use in clinical practice. Biologic agents have been well studied for the treatment of moderate to severe chronic plaque psoriasis, but (...truncated)